The Commonwealth Fund finds cost barriers and limits on care for Medicare beneficiaries consistently places the U.S. low on the list of an 11-nation ranking of how older people fare in industrialized nations. (Shefali Luthra,
11/19)

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Summaries Of The News:

While Maryland and Minnesota report some improvements, officials in Washington state are still holding hearings about issues left over from the 2014 enrollment.

The Associated Press:
Old Health Exchange Problems Overshadow New Ones
Washington's health care exchange had problems last weekend as open enrollment began. But lawmakers, citizens and the members of the board that oversees the Washington Healthplanfinder are more concerned about problems lingering since last year. At a legislative committee meeting Tuesday in Olympia and again at a board meeting Wednesday near Seattle, the refrain heard over and over again was: Why haven't you fixed the problems preventing people from using the insurance they bought during the previous open enrollment period? (Blankinship, 11/19)

The Baltimore Sun:
High Volume Slows Maryland's Health Exchange Website
Heavy volume on the newly opened Maryland health exchange website pushed those looking to buy insurance into virtual waiting rooms for up to a half-hour Wednesday morning. Wednesday had been billed as the day the public would gain full access to the newly rebuilt website. Officials and those using the portal said the online delays were resolved later in the day. The hiccup could reflect the level of interest in buying insurance on the site — which officials said was designed to accommodate thousands of users at a time. (Cohn, 11/19)

Minnesota Public Radio:
Despite Volume, CEO Says MNsure Signups Going Well
More than 4,700 people have used the MNsure website to enroll in public or private health plans since open enrollment for 2015 started Saturday morning. ... An estimated two-thirds of enrollees signed up for government-sponsored health plans. A little more than 1,500 signed up for private health insurance. That's many more than last year at the same time. In the first two weeks of the 2013 enrollment, 400 had signed up.(Zdechlik, 11/19)

Also in the news, state officials questioned the head of the agency overseeing the federal health marketplace about a Supreme Court case that could affect subsidies to help consumers pay for premiums.

The health law's expansion of the low-income health insurance program was a hot topic at this week's Republican Governors Association meeting in Florida. Meanwhile, Montana Gov. Steve Bullock unveiled his Medicaid plan for the state.

The Wall Street Journal:
Republican Governors Set Sights on 2016 Presidential Race
Five of the six governors who are considering a presidential bid appeared on a discussion panel and teased out their differences concerning immigration, Medicaid and other issues. ... The governors exploring presidential campaigns span the party’s spectrum of ideology and style. During the discussion, which included the governors of Louisiana, Indiana, Wisconsin, Texas and Ohio, some of those differences emerged. Indiana Gov. Mike Pence called for repealing the 2010 health care law “lock stock and barrel.” Ohio’s John Kasich defended his state’s decision to expand Medicaid, which has come under fire from the right. (Hook and Haddon, 11/19)

The Wall Street Journal:
Christie’s Strategy on National Issues: Address Some, Not Others
Mr. Christie said the Supreme Court shouldn’t rule on gay marriage, instead leaving it to states to make decisions. He has supported the Keystone XL pipeline—a popular position among the Republican business base. And he has bashed the Affordable Care Act, even as New Jersey accepted a Medicaid expansion that been controversial among conservatives. (Dawsey, 11/19)

Great Falls (Mont.) Tribune:
Medicaid Expansion Plan Is Unveiled
Gov. Steve Bullock on Wednesday officially unveiled a plan to expand Medicaid in Montana in a way he says will provide coverage to nearly 70,000 Montanans in a way that would contract with an insurer in a competitive process to provide coverage through private providers at negotiated rates. The plan is based on the Healthy Montana Kids program, which provides health insurance coverage to children who meet certain guidelines. (Wipf, 11/19)

In addition, Reuters does a status check on how states are faring with this provision of the health law -

Reuters:
U.S. States Get More, Spend More On Medicaid Under Obamacare
One part of the Affordable Care Act is going according to plan, with U.S. states receiving and spending more money on the Medicaid health insurance program, a report released by the National Association of State Budget Officers on Thursday showed. States run Medicaid, which serves families who have low incomes, and receive partial reimbursements from the federal government. The healthcare overhaul known as Obamacare allowed more people to enroll in Medicaid and also gave states 90 percent to 100 percent reimbursements for new enrollees. (11/19)

One entrepreneur has created software that helps people pick the best health plan based on personal factors that go well beyond premium costs, reports The New York Times. Others news outlets examine the challenges facing the SHOP program for small businesses, tax issues related to the health law and the lack of adult vision coverage in health law plans.

The New York Times' Bits:
Chasing Entrepreneurial Opportunity In The Affordable Care Act
Some foes of the Obama administration’s Affordable Care Act portray the law as nothing less than socialist-style government control of American health care. Noah Lang, a health care entrepreneur, is not one of those people. Mr. Lang, chief executive of Stride Health, explains that the Affordable Care Act is one of two major developments in the last few years that have made it possible for a company like his San Francisco start-up to exist. The other big force, he says, is the explosion in available health data, led by government initiatives, notably HealthData.gov. (Lohr, 11/19)

Detroit Free Press:
Hardship Exemption For Health Coverage Can Be Confusing
One quirky twist in the Affordable Care Act is that millions of uninsured people could need a year-end tax checkup, if they want to avoid headaches and penalties when they file their tax returns next year. Sure, taxes are already plenty confusing. But now uninsured people will need to examine why they're uninsured — and in some cases provide documentation — if they want to avoid tax penalties. Truly, we're looking at one mind-numbing tax maze. The Affordable Care Act includes many hurdles that tax filers do not understand yet. I wrote earlier about trip wires that could lead to smaller tax refunds for some who are insured and received the premium tax credit in advance. (Tompor, 11/20)

Vermont, for instance, has said it will not pay him for his work on the state's health plan, and Michigan lawmakers plan to investigate his efforts there. Meanwhile, Rep. Andy Harris, R-Md., questioned a grant awarded to the MIT economist by the National Institutes of Health.

The Wall Street Journal:
Fallout From Gruber’s Remarks Spreads
The fallout over comments made by a Massachusetts Institute of Technology economist about the Affordable Care Act has spread to the states, where both Republicans and Democrats are pulling back from a man who sold his expertise about health systems. Vermont said it won’t continue to pay Jonathan Gruber for his work on its health-insurance plan, which aims to create universal coverage financed with public funds. Michigan lawmakers said they plan to investigate work he did for that state. (Armour, 11/19)

The Associated Press:
'Stupidity' Remark Leads To Free Health Site Work
An economist who said "the stupidity of the American voter" helped pass the complex federal health care law has agreed to finish his work on Vermont's health insurance systems for free, a top state official said Wednesday. But the state will continue to pay assistants working with Jonathan Gruber, an economist at the Massachusetts Institute of Technology who advised the Obama administration as it crafted the Affordable Care Act. Vermont will likely end up paying about $280,000 of the original $450,000 the state had agreed to pay Gruber's team and a subcontractor, said Lawrence Miller, director of health reform for Gov. Peter Shumlin. (Gram, 11/19)

The Washington Post's Fact Checker:
Explainer: What Gruber Meant When He Said ‘If CBO Scored The Mandate As Taxes, The Bill Dies’
What did Gruber mean when he uttered this words in a now-infamous video that has inflamed hostility to the Affordable Care Act? This is a bit of a wonky subject, but we think it is worth explaining, because commentators on both the right and the left have jumped to the wrong conclusion. They assumed Gruber was discussing the fact that the administration had not described penalties for failing to get insurance as “taxes,” even though the Supreme Court later said Obamacare was constitutional because the individual mandate was indeed a tax. But that’s not correct. (Kessler, 11/19)

The Baltimore Sun:
Maryland Rep. Questions NIH Grant To Gruber
Maryland Rep. Andy Harris on Wednesday questioned a National Institutes of Health grant awarded to MIT economist Jonathan Gruber, an administration health care consultant who has come under fire for recent comments about the "stupidity of the American voter." "Recent developments related to Dr. Gruber raise questions about his objectivity and judgment, and thus the utility of his research," Harris and Republican Rep. Joe Pitts of Pennsylvania wrote in a letter to Dr. Francis Collins, the director of Bethesda-based NIH. (Fritze, 11/19)

President Barack Obama is scheduled to announce his executive order on immigration in a speech tonight. Reports indicate it will shield about four million people from deportation, but they won't be able to purchase subsidized health insurance via the health law's online insurance marketplaces.

The New York Times:
Obama’s Immigration Plan Could Shield Four Million
But farm workers will not receive specific protection from deportation, nor will the Dreamers’ parents. And none of the five million immigrants over all who will be given new legal protections will get government subsidies for health care under the Affordable Care Act. These new details about the broad reach of Mr. Obama’s planned executive action on immigration emerged as he prepared to speak to the nation in a prime-time address on Thursday night. (Shear and Pear, 11/19)

The Washington Post's Wonkblog:
Obama’s Order Won’t Extend Obamacare To Undocumented Immigrants
That means the millions who will be protected from deportation won't be eligible to purchase subsidized coverage from the public health insurance marketplaces established under the Affordable Care Act. The decision will disappoint advocacy groups, but it doesn't come as a total surprise. The Obama administration passed on a similar opportunity two years ago to extend health-care eligibility to so-called "dreamers," illegal immigrants who entered the United States as children. In September, the Obama administration said it cut off ACA marketplace coverage to about 115,000 immigrants who failed to provide proof of their citizenship or immigration status. (Millman and Eilperin, 11/19)

The incoming chairman of the House Ways and Means Committee also said the changes might have to wait until a new president is elected. Elsewhere, a former healthcare.gov technology chief says it wasn't his job to know about specific technology problems with the site.

The Washington Post:
Paul Ryan: Obama Already Hurting Chances For 2015 Cooperation
Rep. Paul Ryan, the incoming chairman of the powerful House Ways and Means Committee, laid out an expansive agenda Wednesday for 2015, including a GOP alternative to the Affordable Care Act and a fix for the looming shortfall in the federal disability insurance program. An overhaul of the nation’s tax laws will also rank high on the agenda when Ryan (R-Wis.) takes the helm of the tax-writing panel in January. However, Ryan acknowledged significant hurdles to passing tax reform during President Obama’s final years in office, and said far-reaching legislation may have to wait until a new president is seated in 2017. (Montgomery, 11/19)

The Hill:
GOP Asks Former ObamaCare Official: What Are You Hiding?
Sparks flew Wednesday at a hearing on the botched rollout of HealthCare.gov as Republican lawmakers grilled former White House Chief Technology Officer (CTO) Todd Park about his role in the site's creation. GOP members had sought for almost a year to bring Park before the House Science and Technology Committee, desiring to suss out his level of involvement in the debacle. The administration has consistently argued he was not a key player, though he assisted greatly with the effort to fix the system by the end of November 2013. (Viebeck, 11/19)

Costly hepatitis and cancer treatments helped boost U.S. drug spending this year by almost 12 percent, according to a survey. Meanwhile, Gilead Sciences buys a shortcut for FDA drug review for $125 million, the Justice Department probes big price increases for generic drugs and some Medicare beneficiaries will pay a greater portion of their drug costs.

Reuters:
Drug Spending Tops $1 Trillion On Hep C, Cancer Therapies
Global pharmaceutical spending will break the trillion dollar mark in 2014, driven by high prices in the United States for novel treatments such as Gilead Sciences Inc's Sovaldi for hepatitis C and new cancer drugs, according to a study released on Thursday. Total spending on drugs will hit $1.06 trillion, an increase of 7 percent over 2013 levels, according to the report from the IMS Institute for Healthcare Informatics. The increase also reflected a slowdown in the introduction of cheaper generic versions of branded medicines. (Humer, 11/20)

Kaiser Health News:
Costly Hepatitis C Treatments Help Drive 12 Percent Drug Spending Jump
After several years of modest increases, American spending on medications is projected to shoot up by 12 percent this year, pushing the nation’s drug bill to between $375 billion and $385 billion, according to a report by the IMS Institute for Healthcare Informatics. Several factors are driving the spending spike, including the introduction of expensive new hepatitis C drugs and fewer drug patent expirations than in previous years, the report found. Such expirations typically lead to savings as cheaper generics replace brand-name drugs. (Rabin, 11/20)

NPR:
Gilead Buys Shortcut For FDA Drug Review For $125 Million
How much is a fast track for the Food and Drug Administration review of a new drug worth? Try $125 million. In an auction, Gilead Sciences, a maker of HIV and hepatitis medicines, just bought a coupon good for the accelerated review of a drug of the company's choice from Knight Therapeutics, a Canadian company. The priority review voucher entitles Gilead to move a drug of its choice through the FDA four months faster than the normal track. (Hensley, 11/19)

The Philadelphia Inquirer:
Justice Department, Senate Investigating Generic Drug Price Hikes
The 1984 federal law that spawned the generic pharmaceutical industry was designed to use the basic idea of economic competition to lower the cost of prescription medicine for millions of Americans. The law has largely served its intended purpose. The Centers for Medicare and Medicaid Services said in January that the national rate of retail prescription drug spending slowed in 2012, growing only 0.4 percent because of "numerous drugs losing patent protection, leading to increased sales of lower-cost generics." But no market can be perfect, even good, for every participant all the time, and some of the 12,000 generic drugs on that market have skyrocketed in price in the last 18 months, according to people in the industry. (Sell, 11/20)

The Wall Street Journal's Pharmalot:
Sticker Shock: Some Medicare Part D Beneficiaries Will Pay More Next Year
As the new year approaches, many Americans with prescription drug coverage provided by Medicare Part D may encounter sticker shock. The reason is that more Part D beneficiaries will be expected to pay co-insurance, which means they will be asked to pay a higher percentage of the total cost of their medicines. As many as 66% of Part D plans will apply co-insurance, an increase of 83% from last year, for their top formulary tiers, according to an analysis by Avalere Health, a consulting firm. These tiers include expensive specialty medicines and so-called non-preferred brand-name drugs, which are reimbursed at lower rates. (Silverman, 11/19)

Meanwhile, the government is taking steps to compel scientists to make study results public even when they are not in the interest of drugmakers -

The Wall Street Journal:
NIH Proposes Greater Disclosure Of Clinical Studies
Federal health officials on Wednesday took steps to compel scientists to make clinical study results public even when the findings cut against the interest of pharmaceutical companies. The National Institutes of Health released a proposed rule that would give federal officials more power to enforce a 2007 law that generally called for results of many medical studies to be published. The proposed rule would, for example, typically require researchers to publish later-stage studies even when the FDA doesn’t approve the drug or device being evaluated. (Burton, 11/19)

The survey by Mercer explores the impact of high-deductible plans. Meanwhile, Health News Colorado reports on a survey in that state that found employer health insurance costs are going up 8 percent for 2015, but most continue to offer coverage.

The Kansas City Star:
Per-Employee Health Coverage Costs Rose 5.4% In Kansas City
Newer-style health insurance plans, with lower premiums but high deductibles, are forcing more Kansas City area employees to think twice about the health care dollars they spend. A survey released Wednesday showed that a lot more area employers are offering the new plans as the latest hope to control health care benefit costs. The annual National Survey of Employer-Sponsored Health Plans, by the Mercer professional services company, also found that those costs rose 5.4 percent this year. (Stafford, 11/19)

The study, by the Commonwealth Fund, looked at the health of seniors in America compared to those in 10 other developed nations and also found older Americans were sicker than their counterparts elsewhere.

Kaiser Health News:
Study: American Seniors Face Health Care Gaps, Despite Medicare
Americans older than 65 are more likely to have chronic illnesses and to say they struggle to afford health care – despite qualifying for the federal Medicare program – than are seniors in other industrialized countries, according to a study by the Commonwealth Fund published Wednesday in the journal Health Affairs. The findings, which are based on phone surveys conducted in 11 industrialized countries, highlight gaps in Medicare coverage that should be addressed, said Donald Moulds, one of the study’s authors and executive vice president for programs at the fund. (Luthra, 11/19)

Hawaii is one of only three states that do not have VA medical centers, and a national program allowing veterans to seek care elsewhere has begun there. In Washington, meanwhile, a veteran's mother asks Congress for better suicide prevention services for those experiencing post-traumatic stress disorder.

The Honolulu Star-Advertiser:
VA Sends Health Care Vouchers To Hawaii Vets
A temporary program by the U.S. Department of Veterans Affairs to help veterans receive faster health care has begun in Hawaii with the issuance of thousands of Choice Cards. The Choice Program is a new benefit allowing veterans to receive health care in their communities instead of waiting for an appointment at a VA facility, but uncertainty remains on how it will be implemented. Hawaii and two other states do not have VA medical centers. Hawaii has a VA clinic and a "memorandum of understanding" with the Tripler Army Medical Center. (11/19)

The Associated Press:
Vets' Mom To Congress: Boost Suicide Prevention
Marine Corps veteran Clay Hunt was just 26 when he committed suicide, following tours of duty in Iraq and Afghanistan. Hunt's mother, Susan Selke, told Congress Wednesday that her son reached out to the Veterans Affairs Department time and again but did not receive adequate treatment for post-traumatic stress disorder and other problems. At one point, the VA even lost his medical files. "Clay constantly voiced concerns about the care he was receiving, both in terms of the challenges he faced with scheduling appointments as well as the treatment he received, which consisted primarily of medication," Selke told the Senate Veterans Affairs Committee. (Daly, 11/19)

A selection of health policy stories from California, Massachusetts, Kansas, Illinois, North Carolina, Connecticut and Colorado.

California Healthline:
Tobacco Tax Proposal Set To Rise Again
On Tuesday, anti-smoking advocates announced a new campaign to establish a $2-a-pack tax on cigarettes in California. Organizers were uncertain whether the proposal would take the form of legislation in Sacramento or a statewide ballot measure, or both. (Gorn, 11/19)

Los Angeles Times:
California Health And Child-Welfare Agency May Seek Increase In Tobacco Tax
Under preliminary consideration are proposals to push state lawmakers to tax "e-cigarettes" or increase existing taxes on tobacco products — and even to snag a share of any tax revenue from legalized marijuana sales if California decides to go that route. The agency considering those options, First 5 California, is among a group of agencies and health organizations supported by California's web of tobacco taxes, which brought in an estimated $835 million in the 2013-14 fiscal year, a decline from $1.2 billion in 1999-2000, a year after cigarette taxes last rose. (Willon and Mason, 11/19)

WBUR:
Westminster Pulls Tobacco Ban Proposal
The Westminister Board of Health is withdrawing a proposal to ban tobacco sales in town after staunch opposition. According to the Telegram & Gazette, board member Edward Simoncini Jr. made the motion to withdraw the proposal Wednesday and the board voted 2-1, with Peter Munro voting for and chairwoman Andrea Crete voting against the motion. (11/19)

Boston Globe:
Westminster Drops Proposal To Ban Tobacco Sales
The local board of health on Wednesday abruptly dropped a controversial proposal to ban all tobacco sales in this small central Massachusetts town, one week after hundreds of angry residents forced a public hearing on the plan to come to a raucous close. (Murphy, 11/19)

Los Angeles Times:
Southland Employers Expect 4.8% Hike In Health-Benefit Costs
Southern California employers expect their health-benefit costs to rise 4.8% next year as the economy recovers and mandates under the federal health law kick in, a new survey shows. Nationwide, more people are expected to sign up for health benefits at work during the current open enrollment season as new federal rules begin taking effect in 2015 and penalties increase for being uninsured. (Terhune, 11/19)

The Topeka Capital-Journal:
State Hospital At Risk Of Losing Medicare Payments
The federal government has put Osawatomie State Hospital on notice that if it does not correct problems there in the next three weeks, it will no longer be allowed to bill Medicare for services. But Kari Bruffett, secretary of the Department for Aging and Disability Services, which oversees the hospital, assured a legislative committee Tuesday that a corrective action would soon be in place and the deficiencies at Osawatomie would be fixed before the hospital is terminated from Medicare. (Hancock, 11/18)

The Chicago Sun-Times:
Retired City Employees Protest Looming Hike In Health Care Premiums
Mayor Rahm Emanuel is offering another $400,000 to soften the blow of Round Two of his three-year phase-out of the city’s 55-percent subsidy for retiree health care, but retirees and their City Council allies are holding out for $9 million. That’s how much it would cost to “hold harmless” 2,500 non-Medicare eligible retirees whose pension checks come from the Municipal Employees Pension Fund and to cut in half the increase for those retirees who do qualify for Medicare. (Spielman, 11/20)

Kansas Health Institute News Service:
No Target Date For Final Streamlining System For Kansas Medicaid
A $135 million computer system meant to streamline applications for Kansas social services, including Medicaid, remains without a final "go-live" date more than a year after the rollout was originally scheduled to be completed. Glen Yancey, chief information officer for the Kansas Department of Health and Environment, said Tuesday that his staff is "making final assessments" of the readiness the Kansas Eligibility and Enforcement System, or KEES. Yancey declined to give a rollout target date, though, saying that policymakers above him have to make that call. (Marso, 11/19)

North Carolina Health News:
Providers Work To Ease Effects Of Abortion Law
In 2011, the North Carolina General Assembly pushed through a controversial law that put up what some call barriers to abortion and what others call more informed consent. HB 693 would require teens to have a parent accompany them for reproductive health care. The Woman’s Right to Know law requires a doctor to show a patient ultrasound images and describe them and have the woman sign a form that various stipulations of the law have been performed. Findings from a study done by researchers from UNC-Chapel Hill show that the passage of HB 854 hasn’t affected patients very much, but abortion providers in North Carolina have had to make several changes to the way they operate to comply with the law’s mandates. Mara Buchbinder, who presented the findings at the American Public Health Association Conference in New Orleans this week, told an audience that the study shows that the new law created extra work for providers. (Namkoong, 11/19)

Connecticut Mirror:
Insurance Commissioner Leonardi Stepping Down
Insurance Commissioner Thomas B. Leonardi will step down next month to join an investment banking advisory firm, Gov. Dannel P. Malloy’s office announced Wednesday. Leonardi, who has led the insurance department since shortly after Malloy took office in 2011, had previously headed an investment banking, venture capital and private equity firm, Northington Partners. He will join Evercore, a New York investment banking advisory firm, as a senior advisor focusing on insurance. (Levin Becker, 11/19)

The Denver Post:
Aspen Has No Psych Beds, But It's Pushing Other Ways To Stop Suicides
For drivers stuck in a commuter traffic jam outside Aspen recently, a cheery local-radio announcer issued this advice: "Remember to take care of your mental health." This may seem like an odd reminder in the midst of holiday-festivity announcements in one of the most beautiful and wealth-endowed communities in the country. But the Aspen area is suffering from what some here describe as an epidemic of emotional crises and suicides. The suicide rate in Pitkin County is four times the national average. Four residents took their lives in 11 days early this year. Two more suicides have occurred since then. The dead range from a well-known journalist to a veteran who had lost his legs in Iraq. (Lofholm, 11/20)

Each week, KHN's Shefali Luthra finds interesting reads from around the Web.

The New York Times:
Why Are So Few Blockbuster Drugs Invented Today?
The idea that the human genome would lead to a multitude of cures for diseases seemed inevitable and irresistible. ... Once a malfunctioning gene was isolated, scientists would find the protein coded by that gene. Then they’d use that protein as a target. Finally, they’d run tests of tens of thousands of unique chemical entities that drug companies have stockpiled over the years, to find one that fit the target like a key in a lock, to correct its function. But this golden road to pharmaceutical riches, known as target-based drug discovery, has often proved to be more of a garden path. (Dan Hurley, 11/12)

Vox:
Meet Michael Cannon, The Man Who Could Bring Down Obamacare
Michael Cannon is an ardent Obamacare opponent who runs the health policy program at the libertarian Cato Institute. ... Cannon has spent the past three years testifying in countless statehouses, imploring legislators not to implement Obamacare. Now, he's gotten the Supreme Court listening. ... I spoke with Cannon in mid-November about the case against Obamacare subsidies, how it began, and what it would mean for the Affordable Care Act if this lawsuit succeeded. (Sarah Kliff, 11/19)

The New Republic:
That Silence You Hear Is the Sound of Healthcare.gov Working Just Fine
That ruckus you didn’t hear over the weekend was the sound of Obamacare online marketplaces not failing to work. ... By the time Saturday was over, Health and Human Services Secretary Sylvia Burwell reported, more than 1,000,000 people had shopped for coverage on healthcare.gov and more than 100,000 people had successfully completed applications to buy insurance. ... The overall trend is very clear. Analyses from Avalere, the Kaiser Family Foundation, and PricewaterhouseCoopers all found that, for the market as a whole, premiums have risen very modestly in the last year. (Jonathan Cohn, 11/17).

The Daily Show:
Plan’s Labyrinth
All anyone in Washington is talking about is a tape that emerged recently of an Obamacare consultant telling folks what he really thinks about the Americans buying the insurance. (Jon Stewart, 11/18)

Politico Magazine:
You Think Ebola’s Bad? Try The Black Death
The appearance of the Ebola virus on the shores of America last month, after claiming some 4900 lives in West Africa, is certainly more than a little worrisome. ... But the disease is not nearly as deadly as that which, well, plagued the world in the 14th century. .... in 2007, historian Philip Daileader [provided] a figure that is now viewed as authoritative: “The trend of recent research is pointing to a figure more like 45-50 [percent] of the European population dying during a four year period.” (Mark Perry, 11/18)

The Atlantic:
Why No One Can Design A Better Speculum
The speculum’s history is, like many medical histories, full of dubious ethics. Versions of the speculum have been found in medical texts dating back to the Greek physician Galen in 130 A.D. and shown up in archaeological digs as far back as 79 A.D. amidst the dust of Pompeii. ... there has been no real contender to displace the duck-billed model. The speculum’s history is inextricably linked to extreme racism and misogyny. But for all that, it just may be the best design we’re ever likely to have. (Rose Eveleth, 11/17)

Los Angeles Times:
Take Away The Name And What Is Obamacare But A Checklist Of GOP Values?
A suggested bit of homework for the new GOP Congress: Reread “Romeo and Juliet.” Not for the lovey-dovey bits – a GOP-Dem mutual suicide pact is probably a likelier scenario – but there’s one line the Republicans should keep in mind before trying to pull down Obamacare as if it were a Saddam Hussein statue: Juliet: “’Tis but thy name that is my enemy.” Take away the name and what is Obamacare, but a checklist of solid GOP values? (Patt Morrison, 11/19)

news@JAMA:
Access To Health Care For Millions In Balance As U.S. Supreme Court Reviews Subsidies
When the Supreme Court narrowly upheld the individual health insurance mandate in National Federation of Independent Business v Sebelius (2012), the future of the Affordable Care Act (ACA) appeared secure. However, the case opened the door to 22 states refusing to expand Medicaid coverage for the poor—a major setback for health equity. In addition, 19 states opted for fully federally operated exchanges (marketplaces to purchase insurance), and another 15 for a hybrid system, with the federal government retaining ownership. When states decided not to form state-run exchanges, few experts expected adverse consequences. But all that could change. (Lawrence Gostin, 11/19)

The Wall Street Journal's Washington Wire:
How 13 Million Americans Could Lose Insurance Subsidies
The Supreme Court is expected to rule next year on King v. Burwell, the lawsuit in which the federal government’s authority to provide financial assistance to people who buy insurance in federally operated insurance exchanges is being challenged under a strict reading of the Affordable Care Act. Thirty-seven states have federal exchanges. ... a decision for the plaintiffs would deny financial assistance for insurance premiums to approximately 13 million Americans in 2016. More than half are in a few big anti-ACA states that chose not to run their own exchanges: Florida, Texas, North Carolina, Georgia, and Pennsylvania. But the consequences in other states are not small: In total, 100,000 to 500,000 people in 22 other states would become ineligible for financial assistance. (Drew Altman, 11/19)

The Wall Street Journal:
Obama: The Hangover
Before the U.S. political system goes to the mattresses, I’d like to spend a moment discussing Jonathan Gruber, ObamaCare and the American people. Jon Gruber is the now-famous ObamaCare designer and explainer-for-hire who said the Affordable Care Act became law because the American people were too stupid to understand what was in it. ... Jon Gruber’s remarks matter not for what they say about the Democratic Party’s modus operandi but because of the truths he revealed about the Democratic Party’s reason for being. The Gruber threat to the Democrats isn’t reputational; it’s existential. The Democrats have believed for decades that if they build it—a health-care entitlement or any other federal bestowment—the voters will come. That political model is cracking. (Daniel Henninger, 11/19)

Bloomberg:
GruberGate's Insider Problem
I could try to convince conservatives that the problem is not actually with Gruber, who's basically a smart and, yes, well-meaning guy, for all that we vehemently disagree. The problem is not even really with the Barack Obama administration. The problem is with the system and the way that elites in that system treat others. I could tell them that "conspiracy" is far too strong a word for something that both sides do every time they get the chance. ... What is not inevitable is that journalists should effectively sanction this by saying it's no big deal. ... We shouldn't act like we're part of the insider clique that decides what other people need to know -- no, worse, that decides what other people do know. If we knew this all along and voters didn't, that doesn't mean voters don't have a right to be outraged. It means that we've lost track of whose side we're on. (Megan McArdle, 11/19)

St. Louis Public Radio:
Not Expanding Medicaid Is Hurting Missouri Rural Hospitals
To date, Missouri has failed to expand its Medicaid program as part of the Affordable Care Act, aka "Obamacare." As a result, federal dollars that would normally flow to underserved areas are being transferred to states that have expanded their programs. This loss of funding has major implications for health care in our state especially for those in areas of poverty and who are underserved. One particularly susceptible area is rural Missouri. (Terry Weiss, 11/19)

Los Angeles Times:
Stop The Guessing Game Over Which Doctors Are In-Network
One of the loudest complaints about the policies sold through Covered California, the state's new health insurance exchange, is that they provide access to far fewer doctors than promised. On Wednesday, state regulators finally confirmed and quantified the problem with respect to two leading insurers, Anthem Blue Cross and Blue Shield of California. Yet as is typical in the healthcare industry, it's not entirely clear who's responsible, nor is there an easy fix. (11/19)

Los Angeles Times:
How To Care For Caregivers
Some 39 percent of adults serve as full- or part-time caregivers to a loved one struggling with a disease or disability. You almost certainly know one of them. But do you know what kind of strain they are under? And are you making any effort to support them? In caregiver support groups, I hear the same question again and again: What has happened to all of my friends? Where are they now, when I need them most? (Mary McDaniel Cail, 11/19)

Medscape:
Why Are Doctors And Hospitals The Owners Of Patient Records?
More than half of patients believe they own their records, and nearly 40 percent of physicians think they own their patients' records. Well, these doctors (and hospitals) are right—they legally own the records. But should they? With all of the remarkable issues surrounding a patient's access to her own records, including multiple providers, cost, and inconvenience, isn't it high time for rightful ownership to belong to the consumer? After all, the patient paid for the visit, procedure, lab test, scan, or hospitalization. It's his or her body. For centuries, the medical community believed that patients could not handle seeing their own information for fear that it would induce major anxiety. They also believed that the information wouldn't be understood; medical jargon is much too complicated for a layperson. (Dr. Eric Topol, 11/18)

Journal of the American Medical Association:
Sharing And Reporting The Results Of Clinical Trials
The principle of data sharing dates to the dawn of scientific discovery — it is how researchers from different disciplines and countries form collaborations, learn from others, identify new scientific opportunities, and work to turn newly discovered information into shared knowledge and practical advances. When research involves human volunteers who agree to participate in clinical trials ..., this principle of data sharing properly assumes the role of an ethical mandate. These participants are often informed that such research might not benefit them directly, but may affect the lives of others. If the clinical research community fails to share what is learned, allowing data to remain unpublished or unreported, researchers are reneging on the promise ... and are jeopardizing public trust. (Kathy L. Hudson and Francis S. Collins, 11/19)

The New England Journal of Medicine:
Civil Disobedience And Physicians — Protesting The Blockade Of Medicaid
On May 6, 2013, I was arrested by the North Carolina Capitol Police in front of the doors of the state Senate chamber, protesting our legislature's decision to forgo Medicaid expansion under the Affordable Care Act (ACA). For a practicing physician and professor of medicine, this was an unusual turn of events in an academic career. But given that 23 states have decided not to expand Medicaid, I find it less surprising that I was arrested than that more health care professionals have not taken to the streets to protest the harm being wreaked on our patients by decisions driven by partisan politics. (Dr. Charles van der Horst, 11/20)

The New England Journal of Medicine:
Communicating Uncertainty — Ebola, Public Health, And The Scientific Process
[C]ommunicating uncertainty often undermines perceived expertise, but if you don't communicate uncertainty and end up being wrong, you risk losing even more credibility. Management of the Ebola “crisis” in the United States has crystallized this dilemma. ... Containing the epidemic requires continued efforts by dedicated international health workers and a willingness to trust that though our health authorities cannot know everything, they will do everything they can to protect us with the knowledge they have. (Dr. Lisa Rosenbaum, 11/20)

The New England Journal of Medicine:
Helping Smokers Quit — Opportunities Created By The Affordable Care Act
Several provisions of the Affordable Care Act (ACA) are designed to address the long-standing gap in [tobacco] cessation coverage and thereby increase rates of cessation. Though these provisions have received little publicity, they could contribute greatly to improving the quality of health care and achieving better health outcomes while reducing health care costs. (Dr. Tim McAfee, Stephen Babb, Simon McNabb and Dr. Michael C. Fiore, 11/19)